Doctors Use Tiny Vacuum To Help Stroke Patients

Jane Coleman heard her husband make an odd noise, “almost like hiccups but not exactly,” but when she turned to look at him, she knew immediately what was happening: He was having a stroke.

“His face was twisted,” said Coleman, who’d spent several years as a hospital volunteer. In three minutes, an ambulance was there to take Leroy Coleman not to the hospital nearest his Talbott home, but to the airport, where he was airlifted to Fort Sanders Regional Medical Center.

In the emergency department there, he was immediately given the “clot buster” TPA — tissue plasminogen activator, a protein that breaks down blood clots — but it didn’t work for Coleman. Coleman, then 74, had had the most common non-bleeding type of stroke, a large vessel occlusion, and while TPA works well with smaller clots, it works less than 10 percent of the time when the stroke is the result of a large clot, as Coleman’s was.

So neurointerventional radiologist Dr. Keith Woodward threaded a small, flexible catheter through Coleman’s groin, up behind his eye and into his brain, where he used gentle vacuum suction to pull the clot out.

The procedure, thrombectomy, gained national attention last month when the American Heart Association/American Stroke Association changed its guidelines for treating acute ischemic stroke to include it.

But it’s not a new technique. Woodward began using it when he came to Fort Sanders in 2004; he’d seen it done as a fellow at Vanderbilt University Medical Center.

University of Tennessee Medical Center began the next year, and doctors started performing thrombectomy at Physicians Regional Medical Center around three years ago, said Tennova spokesman Russell Marriott, though those services will likely soon move to Tennova’s Turkey Creek Medical Center as the hospital system transitions Physicians Regional away from being an acute-care hospital.

Initially, the procedure wasn’t quite as effective as it is now. The first catheters weren’t as flexible, so there was more risk of tearing a blood vessel, and they were topped not with suction but with a springlike device intended to fit around the clot and allow the doctor to drag it out.

Woodward did only two of the procedures that first year — mainly, he said, because stroke patients “weren’t getting here” in time to have the procedure. Few doctors or smaller hospitals knew much about it; the scientific evidence to get widespread attention and buy-in was still lacking.

The next few years, he did around 20 a year, but that was enough to see the potential impact: Patients who would have lived out their lives in nursing homes, debilitated by stroke, were going home with near-normal function. Woodward said the procedure carries no major known risks that aren’t present in all stroke patients.

Meanwhile, as the Joint Commission and the American Heart Association declared Fort Sanders a Comprehensive Stroke Center, Woodward focused on educating smaller hospitals in and out of the Covenant Health system on how to diagnosis a patient who should be immediately sent for a thrombectomy. He also participated in clinical trials and was a lead investigator in the Medical University of South Carolina’s COMPASS trial, which compared thrombectomy to other stroke treatments and ended last summer.

About two years ago, he began using the suction device inside of the spring and saw immediate results. Last year he performed 135 thrombectomy procedures; altogether, between Woodward and his partner, more than 574 patients have had one at Fort Sanders.

Coleman, like most patients, was awake for the procedure and, like some, even remembers it clearly. He said he felt no pain, and Woodward said some patients feel only a few seconds of intense pain if the catheter tugs on a nerve behind the eye as it passes by.

Patients aren’t put under for two reasons, Woodward said: Time is of the essence, and he likes to monitor whether function is returning as the clot is removed.

The majority of patients improve within 24 hours, he said, and in about 20 percent, the stroke is reversed immediately.

“I had a (stroke) patient who could not speak,” Woodward said. “You’d ask him what his name was, and he’d say, ‘Aahhh, aahhh.’ As I pulled the clot out, I said, ‘Tell me what your name is.’

“Before I even got the clot out of his body, he said, “My name is — Oh, my God, I can speak again!’ And the guy started crying on the table! It was really powerful to see that.”

Recent studies indicate thrombectomy can be of benefit even 24 hours after surgery, but sooner is always better, said Dr. Brian Wiseman, medical director of UTMC’s comprehensive stroke center and chair of the Tennessee Stroke Task Force.

“Time is brain,” Wiseman said. “The most important factor to improve the odds of a good outcome after stroke is activating EMS to ensure arrival to the hospital as soon as possible after onset of symptoms.”

He recommended using the FAST acronym to remember symptoms of stroke: Facial drooping, Arm weakness, Speech difficulties and Time to call emergency services.

“Since the routine use of clot retrieval devices for stroke, we have seen a dramatic improvement in patient outcomes with very severe strokes,” Wiseman said. “Now patients experiencing very severe stroke have a chance of walking out of the hospital instead of suffering lifelong disability or potentially deadly consequences.”

Coleman, an Army veteran and retired trucker, spent two days in the hospital. Now a year out from his surgery, he’s resumed normal life, including water aerobics and walking two miles a day.

“When I took him to his doctor at the VA, I said, ‘Twenty years ago he would have died,’ ” Jane Coleman said. “She said, ‘TEN years ago, he would have died.’ “

Instead, Coleman returns annually for an ultrasound to check the stent Woodward put in after removing the clot, to open the blockage.

“Six years ago, a 74-year-old man comes in with carotid occlusion; that’s a nursing home for life,” Woodward said. “They were still trying to prove this worked six years ago. Three years ago, they finally showed that not only does it work, it works really, really well.”